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Laser Therapy New Patients Form
First Name
Last Name
Email
Phone
Birthday
1. What is your main condition for this appointment?
2. Is your condition medically diagnosed? If yes, what is it?
3. How long has the condition been? (days, weeks, months, or years)
4. What is the intensity (1-10) of the condition currently?
5. Is the condition worse in the morning vs. afternoon or same throughout the day?
6. Does the condition get worse or better with physical activities or exercises?
7. what is your current Activities of Daily Living (10-100%)?
8. Do you have a health Insurance Plan?
Yes, Please check if my plan will cover the treatment and other service you offer
No, Please offer self pay rates for my future appointments
Not interested
If yes, please provide name of Ins., ID #
Upload Front & Back of Ins.card Image
Upload supported file (Max 15MB)
9. Where is your Preferred Location for your Laser Therapy?
Arlington / Rosslyn Metro Center
Lansdowne / Leesburg
Reston / Herndon
10. When is our prefered day and times for your treatment (check al that applied)?
Mon - Wed
Thurs - Fri
11 AM - 2 PM
4 PM - 8 PM
Schedule me any time
11. Anything else you would like to add?
Submit
Laser Therapy New Patients Form
First Name
Last Name
Email
Phone
Birthday
1. What is your main condition for this appointment?
2. Is your condition medically diagnosed? If yes, what is it?
3. How long has the condition been? (days, weeks, months, or years)
4. What is the intensity (1-10) of the condition currently?
5. Is the condition worse in the morning vs. afternoon or same throughout the day?
6. Does the condition get worse or better with physical activities or exercises?
7. what is your current Activities of Daily Living (10-100%)?
8. Do you have a health Insurance Plan?
Yes, Please check if my plan will cover the treatment and other service you offer
No, Please offer self pay rates for my future appointments
Not interested
If yes, please provide name of Ins., ID #
Upload Front of Ins.card Image
Upload supported file (Max 15MB)
Upload Back of Ins.card Image
Upload supported file (Max 15MB)
9. Where is your Preferred Location for your Laser Therapy?
Arlington / Rosslyn Metro Center
Lansdowne / Leesburg
Reston / Herndon
10. When is our prefered day and times for your treatment (check al that applied)?
Mon - Wed
Thurs - Fri
4 PM - 8 PM
Schedule me any time
11. Anything else you would like to add?
Submit
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